Pain And Addiction: Common Threads XVIIIApril 6, 2017

Mark A. Weiner, MD, DFASAM Section Head of Addiction Medicine

Saint Joseph Mercy Hospital – Ann Arbor

PainandAddictionCommonThreadsXVIIIApril6,2017

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MarkAWeiner,MD,FASAMNodisclosures

!  Board Certified in Internal Medicine !  Board Certified in Addiction Medicine !  Lots of experience helping people who are on

too many drugs including patients with chronic pain who don’t have addiction

!  I am NOT a Pain Medicine Specialist !  A large number of my referrals come from

traditional pain specialists

The good physician treats the disease; the great physician treats the patient who has the disease.

- Sir William Osler (1849-1919)

The first duties of the physician is to educate the masses not to take medicine

- Sir William Osler (1849-1919)

“Fearisthemainsourceofsuperstition,andoneofthemainsourcesofcruelty.Toconquerfearisthebeginningofwisdom.”

―BertrandRussell,UnpopularEssays

!  GDisa78yomanwithahistoryofchroniclowbackpainfor35yearssubsequenttoaworkrelatedaccidentwherealargepalletofautopartsfellonhim.Hehasbeenonmethadone80mgperdayfor20years.HehasahistoryofoneDUIwhen22butdoesnotdrinkformanyyears.HerecentlyhadanMIwith3vCABG9monthsago.HehasahistoryofalargehiatalherniarepairthatiscomplicatedbyanincompetentLESandhashadaspirationpneumoniapreviously(ICUx2).HisPCPretiredandhisnewPCPwillnotcontinuehismedication.HeisgoingintowithdrawalandisterrifiedofaspiratingandhavingananotherMI.

!  JRisa61yowomenwithashistoryofcomplexregionalpainsyndromeofthelowerlegafterakneereplacement5yearsago.Shehadbeentreatedwith100mgfentanylpatchand30mgofdiazepamand30mgofbaclofenperday.ShemovesfromWisconsintoMichigan.ShegoestohernewPCPwhowillnotfillherdiazepam,baclofenorfentanyl.Sheisreferredtoaninterventionalpainclinicthathasa2monthwait.Sheisfoundinherhomebyafriendhavingaseizure.Shespends2weeksinachemicallyinducedcomafollowedby8weeksofphysicalrehab.

Opiatesandsedativesaregreatandeveryoneshouldgetsome!

Opiatesandsedativesarebadandshouldbestoppedimmediatelyoneveryone.

ReasonableApproach

!  Epidemicsarenamedafterinfectionsdiseasesorconditions(e.g,HIV,obesity)

!  Opiatesareinanimateobjects!  Doestheuseof”opiateepidemic”directourfocusonlytothepillsanddrugs?

!  Dowespendallourtimefocusingonreducingtheamountofdrugsandforgetaboutthepatienttakingthedrugs?

!  Multipleopiatereductiontaskforcesinavarietyofinstitutions

!  Providersareterrifiedofpatientswithaddiction!  Providersareterrifiedofpatientonchronicopiatetherapy!  Focusondecreasingamountofpillsprescribed(andforgettingaboutthe

patient)!  NewguidelinestelluswhatNOTTODObutlittlewhatTODO.!  Doctorsprescribing“toomanypills”goingtoprisonincreasesfear

!  Fearthateveryoneonprescribedchronicopiates“mightbeadrugaddict”

!  Newsandguidelinesinvokeopiatereductionacrosstheboard"  Providersareafraidiftheydon’tcomply"  Providersarealsoafraidofharmingtheirpatients"  Patientsareafraidofwithdrawalandpain"  Familiesareafraidtheirlovedonewillsuffer

!  Fearleadstopoordecisionmakingandpooroutcomes!  Fearseemstobeoverridingourcompassion

•  Anesthesiologists–boardedinPainMedicine•  PM&R–boardedinPainMedicine•  PainDoctors–notboardedinPainMedicine•  ER•  PrimaryCare

•  Anesthesiologists–boardedinPainMedicine•  PM&R–boardedinPainMedicine•  PainDoctors–notboardedinPainMedicine•  ER•  PrimaryCare•  AddictionMedicine?????

•  Developmentofhigh-levelsoftoleranceanddependence

•  Withdrawalmayneedtobemedicallymanaged•  Hospitalizationmayberequired•  Medicalcomorbiditymaybepresentrequiringspecialattention

•  Highlevelsofpsychologicaldysfunction•  Conditionimproveswithremovaloftoxicsubstances/medicationandabio-psycho-social-spiritualapproach

•  Neitherimprovesandcanbedangerouswithabruptdiscontinuationathomewithoutsupport

•  Trytobethe“voiceofreason”amidstfearandmisunderstanding

•  Recommendappropriatetreatmentforthepatientandassistthereferringdoctor

•  Determineifpatientismedicallystableoratriskforinstability•  Ifatrisk,refertohigherlevelofcare(hospital,ASAMPPC3.7–4,

emergencyroom)

•  Identifyifaddictionispresentanddifferentiateditfromdependence•  Ifpresentsuggestappropriatetreatmentasapriority

•  Ifaddictionnotpresent,discusswithreferringdoctor/PCPwhatyoucanoffer:

•  Youdon’ttreatpainatall.DocumentandtellPCPtocontinuemedsattheirdiscretionuntilptcanbeplacedelsewhere(hospital,painclinic,etc)

•  Youarewillingtohelpinthetreatmentofpainbyassistinginhelpingpatientstopcurrentregimen.

•  Documentthatyoudiscussedwithpatient(andreferringPCP)thatyouarerecommendingsomethingsthatareoff-label•  SLbuprenorphineforpain•  Phenobarbitalorothermedsforbenzodiazepinewithdrawal

•  Performallthescreeningyoufeelyouneedbeforejumpingin(labs,painpsychologyreferral,psychiatryreferral,etc).Letpatientanddoctorknowthismaytakeafewweekstogetstarted.

•  Don’tPanic!–Breath!•  Ifyoufeelpanicorfearoruncertainty,takeaminutetoseparate

YOURagendafromthePATIENTSagendaandthePCP’sagenda•  Standfirmanddon’tagreetosomethingyouarenotcomfortable

engagingin,forexample•  Prescribingopiateschronically(especiallymethadone)•  Prescribingbenzodiazepines

!  Opiates"  Current dose will become ineffective due to tolerance or hyperalgesia"  Increasing dose will eventually make the situation worse (or kill the patient)"  Most often taper will cause intolerable pain and withdrawal

!  Benzodiazepines"  Current dose will become ineffective due to tolerance"  Increasing dose will eventually make the situation worse (or kill the patient)"  Most often taper will cause intolerable pain, anxiety, insomnia and withdrawal (rarely

seizure)

Areturntosafety

Covington,E.“WeaningDrugsinPatientsWithChronicPain”PresentedatPainandAddiction,CommonThreadsIV,2003

!  MedicationTransition"  Opiates"  usingapartialopioidagonist(i.e.,buprenorphine)

"  Benzodiazepines"  UsingGABAreceptormodifyingagents

!  Availableinseveralforms:"  Buprenexinjection"  GenericSLbuprenorphine*"  TransdermalPatch(Butrans®)"  SuboxoneFilm*:naloxoneadded"  GenericSLBuprenorphine/naloxone*

!  Dosingforchronicpainisoftendifferentthanforchemicaldependency

!  *notFDAapprovedforpain

!  Acts as a mu agonist:"  Partial agonist; ceiling effect for analgesia and respiratory depression "  Slower dissociation = milder withdrawal "  High affinity: will displace some other µ agonists and precipitate

withdrawal "  Antagonist at the kappa receptor

!  Takeacompletemedicalhistory!  Reviewpsychiatrichistory!  Reviewsubstanceabusehistory(includingalcoholand

tobaccouse)!  Getacompletelistofallmedications(currentand

historical)MAPS(andrepeatregularly)!  UrineDrugScreen!  BasicLabs(CBC,Chemprofile,Thyroidfxn,etc)!  Carefullyeducatethepatientastorisks,benefitsand

expectations.

!  Consider all of the following: "  Pain Psychology Consult

"  Early life trauma, abuse, addiction significantly greater than general population

"  Psychiatry consult "  Nutritional consult "  Medicine / Cardiology consult

!  Worseningpaindespiteincreasingdosesofopiates(i.e.,emergenceofhyperalgesia)

!  Emergenceofintolerablesideeffects(esp.mooddisorderandcognitiveimpairment)

!  Lackofimprovementinactivityorsocialinteraction

!  Safetyconcerns(falls,MVA,unintentionaloverdose)

!  Office-based"  Lowerdosesofopioids"  Lowrisk/littlecomorbidity"  3-4hourobservedvisit

!  HospitalBased"  Toxicdosesofopioids(i.e.,medicationtoxicity)"  Highcomorbidity"  Hospitalstay3-5days

BuprenorphineInductionStratification

!  Experienceusingbuprenorphineforpain"  Thetrainingforaddictiondoesnotprovidethisandoftenleadstopoorpaincontrolandsideeffectlimitations

!  Painpsychologycounseling"  Veryhighincidenceoftrauma,abuseandunresolvedgriefinthechronicpainpopulation

!  InterdisciplinaryCareTeamMeetings!  IdentificationandsimultaneoustreatmentofSUDandothermedicalandpsychologicalcomorbidities

!  Patientsreportreducedpainandimprovementinqualityoflifein692–841%

!  Familymembersfrequentlysay“Thankyouforgivingmemy[wife/husband/parent/child]back

!  Patientusually“comesto”bythesecondmonth!  Thisisthebeginningofalongprocess

1–Malinoff,etal;AmJTherapeutics12;379-384(2005)2–Berland,etal;AmJTherapeutics20,316–321(2013)

!  Bio "  medical stabilization when needed to facilitate

treatment (with or without medications) !  Psycho

"  counseling or self-help groups to develop healthy relationships with feelings/emotions/trauma

!  Social "  Also self-help groups but general expansion of healthy

social interaction !  Encourage exercise, good nutrition and spiritual

growth

!  AsAddictionMedicinespecilists,youmaybeinauniquepositiontobethevoiceofreasoninaworldofmisunderstandingandfear

!  Whentreatingpatientswithchronicpainoraddiction,abio-psycho-social-spiritualapproachisneeded

!  Wemustmovepastourownfearsandhelpourcolleaguesfocusonwhatwealreadyknowhowtodo–careforeachandeverypatientthebestwecan

!  Everypatientdeservesourcompassion,respectandunderstanding!  Everydoctorandnursecaringforthispopulationneedsanddeservesour

compassion,respectandunderstanding–thisischallengingwork!

!  Howtoreachme:"  IHAPainManagementConsultants"  734622-5016

"  Email"  mark_weiner@ihacares.com

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